This form is authorized by Section 3103 of the Michigan Natural Resources and
Environmental Protection Act, 1994 PA 451, as amended. Completion of
this form is required of any vessel owner and/or operator operating
on the Great Lakes or St. Lawrence waterway. Any persons who have
contracts for transportation of cargo with an operator that does not
report the use of the approved ballast water management practices
are not eligible for a new grant, loan, or award administered by the
Michigan Department of Environmental Quality (MDEQ).

Completion of this
form will certify compliance with the Michigan Ballast Water
Discharge requirements.

1. Vessel
Information

Vessel Name

Owner

IMO
Number

Flag

Vessel Type

2.
Ballast Water Management

Yes

No

For
oceangoing vessels:

During the last 12 months, has the vessel complied
with the ballast water management practices proposed
by the Shipping Federation of Canada (Attachment A)?

Is
the vessel currently complying with the ballast
water management practices proposed by the Shipping
Federation of Canada (Attachment A)?

For
nonoceangoing vessels:

During the last 12 months, has the vessel complied
with the ballast water management practices proposed
by the Lake Carrier's Association and the Canadian
Shipowners' Association (Attachment B)?

Is
the vessel currently complying with the ballast
water management practices proposed by the Lake
Carrier's Association and the Canadian Shipowners'
Association (Attachment B)?

3.
Responsible Officer's
Signature

Name:

Title:

Date:

Address:

Email:

Phone:

Fax:

The
MDEQ will compile a list of vessels complying with the ballast water
management practices identified above and post the list on the MDEQ Web
site at:

Indicate whether during
the last 12 months the vessel complied with the ballast water management
practices that were proposed by the Shipping Federation of Canada
(Attachment A). Check Yes or No.

Indicate whether the
vessel is currently complying with the above ballast water management
practices. Check Yes or No.

For nonoceangoing vessels:

Indicate whether during
the last 12 months, the vessel complied with the ballast water management
practices that were proposed by the Lake Carrier's Association and the
Canadian Shipowners' (Attachment B). Check Yes or No.

Indicate whether the
vessel is currently
complying with the above ballast water management practices. Check Yes or No.